1. The scar is usually better. It is camouflaged at the brown to regular skin color junction. It hardly ever becomes keloid. I have seen the incision under the breast get keloid more often. The incision under the breast is in plain skin and therefore shows more clearly – at least until it fully matures, hopefully into an inconspicuous line.
2. Access is better. I can easily see in all directions. I can control the procedure more accurately. Sometimes if using the incision under the breast it is hard to see the very top of the breast pocket – especially if there is a prominent rib in the way. This could obscure a bleeding point. I can get a consistently safer outcome with the areola incision.
3. Less bottoming out. The support structures of the fold under the breast are not harmed with the areola incision, and the implant seems to maintain its position better. Often, if the incision is under the breast the implant might descend too low over the next year or two, perhaps because the fold itself is weakened. This gives the breast an unsatisfactory shape, with not enough breast above the nipple and too much below. The nipple might start to point upwards. This does not look good and may need surgical correction.
4. Shape is much better. It is my opinion that if the areola incision is used, the bottom of the implant rests on the breast between the nipple and the crease and is tilted slightly forward, whereas it rests directly on the fold under the breast if the incision is under the breast and the implant is more vertical in orientation. Long term shape is much better with the areola incision as the implant comes down properly as the breast ages. If the incision is under the breast the implant does not come down so readily and often starts to create a bulge in the upper breast area as the breast ages over the years and comes down with gravity. This gives the breast a long look which is not good.